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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER N A i- L ^/ <br /> /6 t 4Lc/ '/V A1_Ca `� ❑Zoning Status; CUP; <br /> OWNER D RESS (Number/Street,City, ate,Zip) f��� Deed Restriction; CSM <br /> y9 ? / // e04- �vr� �C,D-.2_ ,L/d—A./_ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> �G ..5 3 5 3 W 117A4 T S l �QI V L'�`'�'❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AG itfi-/l ..'e <br /> ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CU NT ZONING: ACREAGE: <br /> ❑PARCEL �1 —: G vadro/f 62. 4/496 frontage drawn to scale. <br /> NUMBER / ?� <br /> TOWNSHIP: SE ION: <br /> V( `eoviim - 1/4: '//: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑Sanitary permits <br /> CSM: LOT / SU:DIVISION BLOCK/LOT LAW QA) '' C0`ei ' (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION:. <br /> SC//2 Q2/t/ .Qck /..i x�� UNl/1 Eyl' Ott.* ❑ Zoning District, <br /> . ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> dliZEWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> .25-/ ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> , TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> IL filling/access) <br /> 2ND FLO R: 3RD FLOOR: /(.(4"( <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ��l/ 6-,:, and available options. <br /> (Please round to nearest dollar) <br /> The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes , No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes 2. ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? , Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes EiNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes ®No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► -0 <br /> 545-112(4/08) <br />